<form role="form" name="htmlForm">
	<div class="">
		<div class="form-group">
      		<label  for="templateSelection" class="col-sm-3 control-label">Machote:</label>
      		<div class="col-sm-9 scp-row">
      			<select class="form-control" ng-model="templateSelection" ng-change="loadTemplate()">
	          		<option value="" selected>Selecccione un machote</option>
	          		<option value="-1">Guardar actual como template</option>
	          		<option ng-repeat="t in templates" value="{{t.id}}">{{t.key}}</option>
	      		</select>
	      	</div>
    	</div>
		<div class="form-group">
      		<label  for="info.quality" class="col-sm-3 control-label">Calidad de la muestra:</label>
      		<div class="col-sm-9 scp-row">
      			<select class="form-control" ng-model="info.quality">
	          		<option value="0">Zona de transformación presente</option>
	          		<option value="1">Zona de transformación ausente</option>
	          		<option value="2">Insatisfactoria</option>
	          		<option value="3">Rechazada</option>
	      		</select>
	      	</div>
    	</div>
    	<div class="form-group">
      		<label for="info.category" class="col-sm-3 control-label">Categorización general:</label>
      		<div class="col-sm-9 scp-row">
      			<select class="form-control" ng-model="info.category">
	          		<option value="0">Negativa para lesión intraepitelial</option>
	          		<option value="1">Anormalidades celulares epiteliales</option>
	      		</select>
	      	</div>
    	</div>
    	<div class="form-group">
      		<label  for="info.anormality1" class="col-sm-3 control-label">Anorm. en celulas escamosas:</label>
      		<div class="col-sm-9 scp-row">
      			<select class="form-control" ng-model="info.anormality1">
	          		<option value="0">ASC-US</option>
	          		<option value="1">ASC-H</option>
	          		<option value="2">LEI de bajo grado - NIC I/VPH</option>
	          		<option value="3">LEI de alto grado (NIC II-III/CA In Stu)</option>
	          		<option value="4">LEI de alto grado con sospecha de infibación</option>
	          		<option value="5">Carcinoma escarrocelular infiltrante</option>
	      		</select>
	      	</div>
    	</div>
    	<div class="form-group">
      		<label  for="info.anormality2" class="col-sm-3 control-label">Anorm. en celulas glandulares:</label>
      		<div class="col-sm-9 scp-row">
      			<select class="form-control"  ng-model="info.anormality2">
	          		<option value="0">Células Glandulares Atípicas Sin Ningún Otro Significado</option>
	          		<option value="1">Células Endocervicales Atípicas Sin Ningún Otro Significado</option>
	          		<option value="2">Células Endometriales Atípicas Sin Ningún Otro Significado</option>
	          		<option value="3">Células Endocervicales Atípicas Sospechosas De Neoplasia</option>
	          		<option value="4">Adenocarcinoma endocervical IN SITU</option>
	          		<option value="5">Adenocarcinoma endocervical</option>
	          		<option value="6">Adenocarcinoma endometrial</option>
	          		<option value="7">Otras Neoplasias Malignas</option>
	      		</select>
	      	</div>
    	</div>
    	<div class="form-group">
      		<label   class="col-sm-3 control-label">Microorganismos:</label>
      		<div class="col-sm-9 scp-row "> <!---->
		        <div class="col-sm-6"><input type="checkbox" ng-model="info.micro_0"/>&nbsp;Gardnerella Vaginalis</div>
		        <div class="col-sm-6"><input type="checkbox" ng-model="info.micro_1"/>&nbsp;Trichomonas</div>
		        <div class="col-sm-6"><input type="checkbox" ng-model="info.micro_2"/>&nbsp;Candida</div>
		        <div class="col-sm-6"><input type="checkbox" ng-model="info.micro_3"/>&nbsp;Clamydia</div>
		        <div class="col-sm-6"><input type="checkbox" ng-model="info.micro_4"/>&nbsp;Actinomyces</div>
		        <div class="col-sm-6"><input type="checkbox" ng-model="info.micro_5"/>&nbsp;Herpes</div>
		        <div class="col-sm-2"><input type="checkbox" ng-model="info.micro_6"/>&nbsp;Otros</div><div class="col-sm-10"><input  class="form-control" ng-model="info.micro_others"></input></div>
	      	</div>
    	</div>
    	<div class="form-group">
      		<label  class="col-sm-3 control-label">Otros Hallazgos no neoplasicos:</label>
      		<div class="col-sm-9 scp-row">
      			<div class="col-sm-6"><input type="checkbox" ng-model="info.otroneo_0"/>&nbsp;Asociados a inflamación</div>
		        <div class="col-sm-6"><input type="checkbox" ng-model="info.otroneo_1"/>&nbsp;Asociados a radiación</div>
		        <div class="col-sm-6"><input type="checkbox" ng-model="info.otroneo_2"/>&nbsp;Cambios asociados a DIU</div>
		        <div class="col-sm-6"><input type="checkbox" ng-model="info.otroneo_3"/>&nbsp;Celulas glandulares post histerectomía</div>
		        <div class="col-sm-6"><input type="checkbox" ng-model="info.otroneo_4"/>&nbsp;Atrofia</div>
		        <div class="col-sm-6"><input type="checkbox" ng-model="info.otroneo_5"/>&nbsp;Celulas endometriales</div>
		        <div class="col-sm-2"><input type="checkbox" ng-model="info.otroneo_6"/>&nbsp;Otros</div><div class="col-sm-10"><input  class="form-control" ng-model="info.otroneo_others"></input></div>
      		</div>
    	</div>
	</div>
</form>